Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

ESR and EISCAT observations of the response of the cusp and cleft to IMF orientation changes

We report observations of the cusp/cleft ionosphere made on December 16th 1998 by the EISCAT (European incoherent scatter) VHF radar at Tromsø and the EISCAT Svalbard radar (ESR). We compare them with observations of the dayside auroral luminosity, as seen by meridian scanning photometers at Ny Ålesund and of HF radar backscatter, as observed by the CUTLASS radar. We study the response to an interval of about one hour when the interplanetary magnetic field (IMF), monitored by the WIND and ACE spacecraft, was southward. The cusp/cleft aurora is shown to correspond to a spatially extended region of elevated electron temperatures in the VHF radar data. Initial conditions were characterised by a northward-directed IMF and cusp/cleft aurora poleward of the ESR. A strong southward turning then occurred, causing an equatorward motion of the cusp/cleft aurora. Within the equatorward expanding, southward-IMF cusp/cleft, the ESR observed structured and elevated plasma densities and ion and electron temperatures. Cleft ion fountain upflows were seen in association with elevated ion temperatures and rapid eastward convection, consistent with the magnetic curvature force on newly opened field lines for the observed negative IMF By. Subsequently, the ESR beam remained immediately poleward of the main cusp/cleft and a sequence of poleward-moving auroral transients passed over it. After the last of these, the ESR was in the polar cap and the radar observations were characterised by extremely low ionospheric densities and downward field-aligned flows. The IMF then turned northward again and the auroral oval contracted such that the ESR moved back into the cusp/cleft region. For the poleward-retreating, northward-IMF cusp/cleft, the convection flows were slower, upflows were weaker and the electron density and temperature enhancements were less structured. Following the northward turning, the bands of high electron temperature and cusp/cleft aurora bifurcated, consistent with both subsolar and lobe reconnection taking place simultaneously. The present paper describes the large-scale behaviour of the ionosphere during this interval, as observed by a powerful combination of instruments. Two companion papers, by Lockwood et al. (2000) and Thorolfsson et al. (2000), both in this issue, describe the detailed behaviour of the poleward-moving transients observed during the interval of southward Bz, and explain their morphology in the context of previous theoretical work

Annual and semiannual variations in the ionospheric F2-layer: I Modelling

Annual, seasonal and semiannual variations of F2-layer electron density (NmF2) and height (hmF2) have been compared with the coupled thermosphere-ionosphere-plasmasphere computational model (CTIP), for geomagnetically quiet conditions. Compared with results from ionosonde data from midlatitudes, CTIP reproduces quite well many observed features of NmF2, such as the dominant winter maxima at high midlatitudes in longitude sectors near the magnetic poles, the equinox maxima in sectors remote from the magnetic poles and at lower latitudes generally, and the form of the month-to-month variations at latitudes between about 60°N and 50°S. CTIP also reproduces the seasonal behaviour of NmF2 at midnight and the summer-winter changes of hmF2. Some features of the F2-layer, not reproduced by the present version of CTIP, are attributed to processes not included in the modelling. Examples are the increased prevalence of the winter maxima of noon NmF2 at higher solar activity, which may be a consequence of the increase of F2-layer loss rate in summer by vibrationally excited molecular nitrogen, and the semiannual variation in hmF2, which may be due to tidal effects. An unexpected feature of the computed distributions of NmF2 is an east-west hemisphere difference, which seems to be linked to the geomagnetic field configuration. Physical discussion is reserved to the companion paper by Rishbeth et al

Annual and semiannual variations in the ionospheric F2-layer: II. Physical discussion

The companion paper by Zou et al. shows that the annual and semiannual variations in the peak F2-layer electron density (NmF2) at midlatitudes can be reproduced by a coupled thermosphere-ionosphere computational model (CTIP), without recourse to external influences such as the solar wind, or waves and tides originating in the lower atmosphere. The present work discusses the physics in greater detail. It shows that noon NmF2 is closely related to the ambient atomic/molecular concentration ratio, and suggests that the variations of NmF2 with geographic and magnetic longitude are largely due to the geometry of the auroral ovals. It also concludes that electric fields play no important part in the dynamics of the midlatitude thermosphere. Our modelling leads to the following picture of the global three-dimensional thermospheric circulation which, as envisaged by Duncan, is the key to explaining the F2-layer variations. At solstice, the almost continuous solar input at high summer latitudes drives a prevailing summer-to-winter wind, with upwelling at low latitudes and throughout most of the summer hemisphere, and a zone of downwelling in the winter hemisphere, just equatorward of the auroral oval. These motions affect thermospheric composition more than do the alternating day/night (up-and-down) motions at equinox. As a result, the thermosphere as a whole is more molecular at solstice than at equinox. Taken in conjunction with the well-known relation of F2-layer electron density to the atomic/molecular ratio in the neutral air, this explains the F2-layer semiannual effect in NmF2 that prevails at low and middle latitudes. At higher midlatitudes, the seasonal behaviour depends on the geographic latitude of the winter downwelling zone, though the effect of the composition changes is modified by the large solar zenith angle at midwinter. The zenith angle effect is especially important in longitudes far from the magnetic poles. Here, the downwelling occurs at high geographic latitudes, where the zenith angle effect becomes overwhelming and causes a midwinter depression of electron density, despite the enhanced atomic/molecular ratio. This leads to a semiannual variation of NmF2. A different situation exists in winter at longitudes near the magnetic poles, where the downwelling occurs at relatively low geographic latitudes so that solar radiation is strong enough to produce large values of NmF2. This circulation-driven mechanism provides a reasonably complete explanation of the observed pattern of F2 layer annual and semiannual quiet-day variations

An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction

BACKGROUND: The relative efficacy of streptokinase and tissue plasminogen activator and the roles of intravenous as compared with subcutaneous heparin as adjunctive therapy in acute myocardial infarction are unresolved questions. The current trial was designed to compare new, aggressive thrombolytic strategies with standard thrombolytic regimens in the treatment of acute myocardial infarction. Our hypothesis was that newer thrombolytic strategies that produce earlier and sustained reperfusion would improve survival. METHODS: In 15 countries and 1081 hospitals, 41,021 patients with evolving myocardial infarction were randomly assigned to four different thrombolytic strategies, consisting of the use of streptokinase and subcutaneous heparin, streptokinase and intravenous heparin, accelerated tissue plasminogen activator (t-PA) and intravenous heparin, or a combination of streptokinase plus t-PA with intravenous heparin. ("Accelerated" refers to the administration of t-PA over a period of 1 1/2 hours--with two thirds of the dose given in the first 30 minutes--rather than the conventional period of 3 hours.) The primary end point was 30-day mortality. RESULTS: The mortality rates in the four treatment groups were as follows: streptokinase and subcutaneous heparin, 7.2 percent; streptokinase and intravenous heparin, 7.4 percent; accelerated t-PA and intravenous heparin, 6.3 percent, and the combination of both thrombolytic agents with intravenous heparin, 7.0 percent. This represented a 14 percent reduction (95 percent confidence interval, 5.9 to 21.3 percent) in mortality for accelerated t-PA as compared with the two streptokinase-only strategies (P = 0.001). The rates of hemorrhagic stroke were 0.49 percent, 0.54 percent, 0.72 percent, and 0.94 percent in the four groups, respectively, which represented a significant excess of hemorrhagic strokes for accelerated t-PA (P = 0.03) and for the combination strategy (P < 0.001), as compared with streptokinase only. A combined end point of death or disabling stroke was significantly lower in the accelerated-tPA group than in the streptokinase-only groups (6.9 percent vs. 7.8 percent, P = 0.006). CONCLUSIONS: The findings of this large-scale trial indicate that accelerated t-PA given with intravenous heparin provides a survival benefit over previous standard thrombolytic regimen